As Korea becomes an aging society, the importance of nutritional care for hospitalized patients is increasing. Nutritional status is closely related to clinical outcomes. For hospitalists managing patients throughout their hospitalization, from admission to discharge, assessing nutritional status and providing appropriate nutrition are essential. Hospitalists must diagnose and treat diseases and ensure that patients receive adequate nutritional support to improve recovery and health outcomes.
Big data has become an important research resource in internal medicine. Major data sources in Korea include national claims databases, health screening records, registry data, mortality statistics, survey data, hospital electronic health records, and emerging biobig data resources. These datasets provide new opportunities for disease surveillance, outcome prediction, and evaluation of real-world practice across a wide range of chronic diseases. Nevertheless, large-scale data do not guarantee valid evidence. Diagnostic misclassification, limited clinical details, incomplete medication information, residual confounding, and difficulties in data linkage and standardization remain major challenges. Therefore, the value of big data in internal medicine depends not only on data volume but also on data quality, appropriate linkage, validated definitions, and rigorous study design. Big data should be recognized as a complementary tool that can strengthen, but not replace, clinical reasoning and conventional clinical research.
Left atrial dissection is a rare complication of cardiac surgery, particularly following mitral valve procedures. Its clinical presentation varies, and the optimal management remains uncertain. Here, we report the case of a 76-year-old woman who developed left atrial dissection after mitral valve replacement and endoatriectomy for circumferential “eggshell” calcification of the left atrium. Postoperative echocardiography and cardiac computed tomography revealed a false lumen along the left atrial wall without inflow obstruction or pulmonary venous compromise. Because the patient remained hemodynamically stable and prosthetic valve function was preserved, she was managed conservatively using serial imaging and clinical monitoring. Over the ensuing months, the false lumen progressively regressed, and follow-up imaging at 6 months confirmed complete resolution. This case highlights the potential for spontaneous healing of left atrial dissection and suggests that conservative management may be an appropriate treatment strategy in stable patients without hemodynamic deterioration.
Effective pain management for hospitalized individuals plays a crucial role in healthcare, affecting patient outcomes, and emotional and overall health. Successful pain management necessitates understanding the essence of pain and comprehending the efficacy and potential side effects of medications tailored to specific types of pain. This article reviews strategies for assessing pain and outlines principles for managing pain using opioids, non-opioid analgesics, and supplementary analgesics with the aim of improving overall quality of patient care.
A 33-year-old man was referred for evaluation of a 4-cm subepithelial mass located in the gastric fundus, initially suspected to be a gastrointestinal stromal tumor based on endoscopic findings. Abdominal computed tomography revealed a well-enhancing mass along the gastric wall, with no apparent anatomical continuity with the liver. Endoscopic ultrasonography demonstrated a well-circumscribed, hypoechoic lesion confined to the serosal layer, suggesting an extramural origin. Subsequent magnetic resonance imaging showed arterial phase enhancement with persistent delayed enhancement and a central hypointense area characteristic of focal nodular hyperplasia (FNH). Laparoscopic resection was performed, and intraoperative indocyanine green fluorescence confirmed the hepatic origin of the mass. Histopathological analysis confirmed FNH arising from an accessory lobe of the liver. This case underscores the importance of recognizing the atypical presentations of hepatic lesions and highlights the diagnostic value of sequential imaging modalities for distinguishing hepatic tumors from gastric subepithelial lesions.
Non-steroidal mineralocorticoid receptor antagonists (NS-MRAs) have emerged as a novel therapeutic class while minimizing the endocrine adverse effects associated with steroidal MRAs, such as spironolactone and eplerenone. Finerenone, the first clinically approved NS-MRA, exhibits high receptor selectivity, minimal off-target hormonal activity, and exerts potent anti-inflammatory and antifibrotic actions that complement renin-angiotensin system inhibition and sodium-glucose cotransporter-2 (SGLT2) inhibitor therapy. The pivotal FIDELIO-DKD and FIGARO-DKD trials demonstrated clinically meaningful reductions in kidney disease progression and cardiovascular composite outcomes in patients with type 2 diabetes and albuminuric chronic kidney disease (urine albumin-creatinine ratio ≥ 30 mg/g), the pooled FIDELITY analysis confirmed consistent cardiorenal benefits across diverse risk strata. Hyperkalaemia remains a principal safety concern and requires potassium monitoring and dose adjustments in routine practice. Emerging short-term data on albuminuria suggest the additional benefits of concomitant SGLT2 inhibitor therapy, although definitive outcome evidence for combination strategies is still evolving. Ongoing clinical programs further extend the therapeutic scope of finerenone to heart failure with preserved ejection fraction, non-diabetic chronic kidney disease, and type 1 diabetes. Collectively, NS-MRAs provide a mechanistically distinct strategy targeting inflammation and fibrosis and represent an important therapeutic advance in integrated cardiorenal-metabolic risk reduction.
Sarcopenia is characterized by progressive loss of skeletal muscle mass accompanied by a decline in muscle strength and/or physical performance. Sarcopenia may develop in patients with end-stage kidney disease due to multiple contributing factors, including uremia, malnutrition, reduced physical activity, chronic inflammation, and dialysis-related factors. In this population, sarcopenia is strongly associated with decreased quality of life and increased mortality, underscoring the need for early diagnosis and timely intervention. This review was written to provide a comprehensive overview of sarcopenia pathophysiology, diagnostic criteria, and prevalence, and describe therapeutic strategies for sarcopenia in patients undergoing dialysis.
The endoscopic diagnosis of gastric subepithelial lesions (SELs) relies primarily on gross features, including shape, color, surface characteristics, mobility, and size. However, endoscopic inspection alone is insufficient for a definitive diagnosis because SELs are covered by normal mucosa and originate from the deeper layers of the gastric wall. Recent guidelines from Korea, the United States, and Europe recommend endoscopic ultrasonography (EUS) to ascertain the lesion characteristics and layer of origin. The updated Korean guidelines recommend periodic endoscopic surveillance for asymptomatic lesions < 10 mm in size. In contrast, lesions ≥ 20 mm or those with highrisk features may warrant histologic confirmation, with tissue acquisition typically undertaken via mucosal incision-assisted biopsy (MIAB) and EUS-guided fine needle aspiration or biopsy (EUS-FNA/B). For lesions < 20 mm, MIAB demonstrates a superior diagnostic yield than EUS-FNA/B. The therapeutic options include endoscopic submucosal dissection, submucosal tunneling endoscopic resection, and endoscopic full-thickness resection. The treatment selection should be individualized based on lesion characteristics, operator expertise, and institutional resources to ensure safe and effective management.
Breast cancer is the most common malignancy among women in Korea and its incidence is rapidly increasing. Perioperative systemic treatment plays a critical role in achieving a cure for early-stage breast cancer. With the introduction of novel systemic agents, treatment outcomes have improved and perioperative strategies have become increasingly diverse. In addition to conventional anthracycline- and taxane-based chemotherapies, targeted therapies and/or immunotherapy have expanded the options to both neoadjuvant and adjuvant settings. Increasing numbers of (neo) novel adjuvant agents and post-neoadjuvant treatments have demonstrated survival benefits, supporting more individualized perioperative treatment approaches in patients with early breast cancer.
A 74-year-old woman with liver cirrhosis presented with hepatorenal syndrome and was treated with terlipressin and albumin. Despite a transient improvement in renal function, the patient developed bilateral toe cyanosis and necrosis during treatment. Computed tomography angiography revealed moderate and severe stenosis of the right and left dorsalis pedis arteries, respectively. Terlipressin was discontinued immediately, and surgical amputation was considered, but deferred because of poor cardiac and hepatic reserves. The patient received conservative wound care but eventually died of multi-organ failure. This case suggests that terlipressin-induced peripheral ischemia can be exacerbated in patients with pre-existing peripheral arterial stenosis or severe cardiac dysfunction. In such high-risk patients, careful evaluation of the vascular and cardiac status before therapy and close monitoring during treatment may help reduce the risk of this rare but serious complication.
Sjögren’s disease (SjD) is a systemic autoimmune disorder characterized by glandular dysfunction and diverse extraglandular manifestations. Despite a strong immunological rationale, many immunomodulatory trials have failed to show consistent efficacy, largely due to clinical heterogeneity and limitations of conventional outcome measures. Growing evidence indicates a dissociation between systemic inflammatory activity and patient-reported symptom burden, leading to recent trials stratifying patients into systemic activitydominant and symptom-dominant phenotypes and aligning primary endpoints accordingly. The European Alliance of Associations for Rheumatology (EULAR) Sjögren’s Syndrome Disease Activity Index (ESSDAI) remains a key endpoint for systemic disease activity; however, it is affected by intrinsic variability and regression to the mean, contributing to high placebo responses. The EULAR Sjögren’s Syndrome Patient Reported Index (ESSPRI) captures core symptoms but demonstrates limited sensitivity to change and weak correlations with objective glandular function. To address these limitations, composite response measures, such as Composite of Relevant Endpoints for Sjögren's Syndrome (CRESS) and Sjögren's Tool for Assessing Response (STAR), have been developed to integrate systemic activity, symptoms, glandular function, and serologic markers. Recent phase 2 randomized controlled trials have demonstrated this paradigm shift. Inhibition of the CD40-CD40L pathway with dazodalibep and iscalimab showed efficacy when phenotype-appropriate endpoints were applied. B-celldirected therapies, including B-cell activating factor (BAFF) receptor blockade with ianalumab and BAFF/A Proliferation Inducing Ligand dual inhibition with telitacicept, have demonstrated improvements in systemic activity with supportive biomarker changes. Remibrutinib, an oral Bruton's tyrosine kinase (BTK) inhibitor, improves systemic disease activity; however, symptom-based endpoints remain a challenge. Neonatal Fc receptor (FcRn) blockade with nipocalimab reduced clinical disease activity in seropositive high-activity subgroups without consistent symptom improvement. Overall, effective therapeutic development for SjD requires mechanism-informed patient stratification and endpoint strategies that link biological activity to clinically meaningful outcomes.
A diagnosis of spondyloarthritis is often delayed because chronic back pain is frequently misidentified as mechanical in origin. Early recognition of inflammatory back pain and its extra-articular manifestations is crucial for preventing irreversible structural damage. In this report, the case of a 25-year-old male with a one-year history of insidious back pain and alternating buttock pain is presented. Despite normal Schober test results and ambiguous initial radiographs, the patient had classic features of spondyloarthritis, including peripheral arthritis, acute anterior uveitis, a positive family history, and HLA-B27 positivity. Although the 1984 modified New York criteria require radiographic evidence of sacroiliitis, modern diagnostic roadmaps use the 2009 Assessment of SpondyloArthritis International Society criteria. In this case, magnetic resonance imaging revealed significant subchondral bone marrow edema in the sacroiliac joints, confirming a diagnosis of axial spondyloarthritis. By integrating clinical features, laboratory markers, and advanced imaging findings, clinicians can navigate the diagnostic roadmap to ensure timely intervention and improve the long-term prognosis of young patients presenting with chronic back pain.
Ischemic colitis (IC), a common cause of lower gastrointestinal bleeding, is typically managed with conservative treatment. However, when hematochezia persists despite endoscopic hemostasis, radiologic intervention becomes a viable therapeutic alternative. This report aims to present three cases of IC associated with massive bleeding successfully treated using radiologic therapies. One patient with IC secondary to occlusive disease, characterized by significant stenosis at the superior mesenteric artery orifice, underwent stent placement, while the other two patients with non-occlusive IC were treated with embolization using microcatheters and Gelfoam. All cases resulted in technical and clinical success, with no procedure-related complications. This case series highlights the potential role of radiologic intervention as an effective, minimally invasive treatment option for select patients with IC who present with persistent hematochezia despite conservative or endoscopic management.
Background/Aims: Since enforcement of the Life-Sustaining Treatment (LST) Decisions Act, a pilot project for medical insurance reimbursement related to LST decisions and their implementation began in February 2018. This pilot project transitioned into a full-scale project in January 2022 that continues to this day.Methods: We observed trend changes in LST decisions and their implementation by performing an interrupted time series analysis of data from the Health Insurance Review and Assessment Service from February 2018 to September 2023. We focused on two events: coronavirus disease 2019 (COVID-19) and the transition to a full-scale project.Results: Our interrupted time-series analysis used the onset of COVID-19 (January 2020) as its reference point. The slopes of most codes for LST decisions and their implementation decreased following the onset of COVID-19. When divided by hospital class, all codes in hospitals, nursing hospitals, and oriental medicine hospitals showed immediate increases before and after the COVID-19 outbreak. A separate interrupted time series analysis was conducted using the transition to a full-scale project (January 2022) as the reference point. While no immediate effects were observed before or after transitioning to full-scale projects, in the institution-specific data, the slopes of all codes in general, nursing, and oriental medicine hospitals increased.Conclusions: Our results reveal that COVID-19 and the transition to a full-scale project have significantly impacted LST decisions and their implementation. These findings can be used to evaluate and improve reimbursement programs.
Chronic kidney disease (CKD) is undergoing a paradigm shift as genetic insights have reshaped its diagnosis and management. Rare monogenic variants explain a growing number of early onset and familial cases, while polygenic risk scores offer new tools for risk stratification. Emerging research, especially from Korean cohorts, has revealed modifiable gene-environment interactions and integrates genomics with metabolomics to uncover disease-specific pathways. Genetic testing plays a pivotal role in clinical reclassification and therapeutic decision-making. With the expansion of kidney genetics clinics, generalists and specialists must adapt to this era of precision. The journey from genes to clinics is no longer conceptual; rather, it redefines CKD care.
The 2024 medical conflict in Korea, often summarized as a ‘medical crisis’, exposed not only the fragility of the healthcare delivery system, but also the vulnerable foundations of undergraduate and postgraduate medical education. The abrupt withdrawal of residents and the prolonged disruption of clinical teaching did not merely create a temporary gap in the curriculum, it left a deep fissure in the development of an entire generation of physicians and medical professionals. As a clinician-educator in internal medicine, the author came to regard this crisis less as a political dispute and more as an invitation to revisit three fundamental questions about medical education: what we have been teaching, for whom we have been teaching, and how we can teach together. This article reflects on these three questions from the perspective of the educational field after the crisis and explores the internal limitations of current medical education, which centers on knowledge transmission, examination performance, and short-term workforce needs. Based on this reflection, three directions are proposed for rebuilding medical education after the crisis: healing students’ trauma and restoring a psychologically safe learning environment; restructuring curricula around core professional and civic competencies; and redefining educational governance through the stable participation of all stakeholders. Drawing on these proposals, this article argues that medical education in Korea should become a central arena for recovering public trust and re-articulating the social meaning of being a physician.
According to Medical Law, internal medicine is an essential medical course for the opening of a general hospital, and covers many departments of medical treatment under its jurisdiction. Due to the characteristics of the disease group and patients, patients with mild-to-severe disease are widely distributed. The uncertainty and difficulty in ensuring treatment outcomes, such as complex and multidisciplinary interventions for multiple diseases, have increased. As such, the increase in interventions in medical practice, specifically linked to patient survival, leads to an increase in the risk of medical accidents. Internal medicine also shows a high status in the initiation of mediation and medical evaluation. To help prevent and resolve medical disputes in the internal medicine field, this paper presents the current status of those disputes and the core legal principles of the Supreme Court for each medical practice, and suggests the author's opinion based on the experience of handling internal medicine cases.
Despite remarkable advances in medical technology, the increasing number of high-risk elderly patients and rising patient expectations have led to an increase in medical disputes in Korea. Internal medicine faces particularly high litigation risks owing to disease complexity and unpredictable outcomes, contributing to a decline in its attractiveness as a specialty. This study analyzed internal medicine disputes using the data from the Korea Medical Dispute Mediation and Arbitration Agency from 2020 to 2024. In 5 years, 1,468 internal medicine disputes were filed, representing 13.8% of the total disputes and ranking second after orthopedic surgery. Common causes included symptom deterioration (32.5%), delayed diagnosis (8.2%), and nerve injury (7.6%), with the highest frequency observed in patients aged 70-79 years. The average claimed amount was KRW 117 million, while the actual settlement averaged only KRW 11 million. The mean interval from incident to filing was 336.6 days. Korea's medical dispute system has evolved from requiring patients to prove negligence to imposing stronger explanatory duties on physicians based on reasonable probability. However, international comparisons reveal Korea's exceptionally high criminalization of medical practice, with prosecution rates approximately 15 times higher than those of Japan and 580 times higher than those of the United Kingdom. Current challenges, such as committee composition dominated by non-medical professionals, insufficient no-fault compensation, and low national health insurance reimbursement rates, are paradoxically driving litigation. Moreover, reforms are essential for sustaining essential medical services; hence, institutional improvements should include establishing objective advisory systems through medical societies, expanding no-fault compensation programs, and restricting criminal prosecution to gross negligence or intentional harm.
FLT3 mutations occur in approximately 25% to 30% of newly diagnosed cases of acute myeloid leukemia (AML) and are typically associated with adverse prognoses characterized by a high risk of relapse. In recent years, the AML therapeutic landscape has been notably reshaped by the introduction of FLT3 inhibitors, including midostaurin, quizartinib, and gilteritinib. The European LeukemiaNet 2022 guidelines classify all FLT3-ITD-positive AML as intermediate risk, regardless of allelic ratios, thereby highlighting the importance of co-mutations and measurable residual disease (MRD). In fit patients (intensive chemotherapy eligible), the current standard therapy incorporates FLT3 inhibitor-based chemotherapy, allogeneic hematopoietic stem cell transplantation during the initial complete remission, and post-transplant maintenance. Long-term follow-up from the RATIFY trial confirmed durable survival benefits using midostaurin (10-year overall survival, 43.7%), whereas the QuANTUM-first study has provided evidence for the marked efficacy of quizartinib in patients with NPM1 and DNMT3A co-mutations. For unfit patients, although azacitidine plus venetoclax remains the standard therapy, early-phase studies evaluating FLT3 inhibitor-containing triplet regimens have revealed complete remission rates exceeding 80%. In addition, for cases of relapsed or refractory FLT3-mutated AML, gilteritinib has been established to provide a median overall survival of 9.3 months and serves as an effective bridge to transplantation, whereas venetoclax combinations can contribute to enhancing the length of remission. Recent advances in characterizing resistance mechanisms, including secondary TKD mutations and RAS/MAPK pathway activation, are contributing to the developments of next-generation covalent and multi-kinase FLT3 inhibitors, and it is anticipated that MRD-guided therapeutic adaptation and genomics-driven precision medicine will facilitate further refinement of future standards of the care.
Clostridioides difficile infection (CDI) poses a diagnostic challenge in patients with inflammatory bowel disease (IBD), as symptoms and endoscopic findings frequently overlap with those of disease flares, and asymptomatic colonization is relatively common. Consequently, positive microbiological test results do not always indicate active infection. We report the case of a 53-year-old woman with ulcerative colitis (UC) who presented with worsening bloody diarrhea and abdominal pain during maintenance therapy with infliximab. At initial admission, she had clinically significant diarrhea with elevated inflammatory markers. Stool testing demonstrated concordant positivity for glutamate dehydrogenase (GDH) antigen and toxin A/B enzyme immunoassay, supporting a diagnosis of active CDI concomitant with a UC flare. Treatment with oral vancomycin led to clinical improvement. Three weeks later, the patient re-presented with mild recurrent diarrhea. Repeat stool testing showed discordant results, including negative toxin A/B but positive GDH, polymerase chain reaction, and culture. Given the mild symptoms, normal inflammatory markers, and spontaneous symptom resolution without further antimicrobial therapy, these findings were interpreted as colonization or residual test positivity rather than recurrent CDI. This case illustrates key principles in CDI diagnosis: testing should be guided by the presence of clinically significant diarrhea, multistep diagnostic algorithms must be interpreted in the clinical context, and positive molecular or culture-based results in IBD patients do not necessarily reflect active infection. Symptom-based assessment is essential to avoid overdiagnosis and unnecessary antimicrobial treatment in patients with UC and suspected CDI.
